Tools and Templates for Acute Care

Resources developed by Nebraska ASAP are intended for non-commercial educational and quality improvement purposes.  Please acknowledge Nebraska ASAP when they are used.

Below is a collection of tools and templates developed for acute care facilities.  These documents can be adopted to the needs of individual facility for improvement in antibiotic prescribing practices.

Adverse Drug Reaction Worksheet (PDF format) (Word format)

Antibiogram template for frequently isolated pathogens, with summary comments

Antimicrobial stewardship intervention database template

Antimicrobial stewardship recommendation form template

Antimicrobial stewardship self-assessment instrument for acute care hospitals

Automatic IV to PO antibiotic conversion policy template

Blacklight Tracking Workbook

Daily antibiotic therapy checklist template

Institutional policy template for hospital ASP

Leadership support statement template for hospital ASP

Piperacillin-tazobactam therapy checklist template

Page last reviewed: September 30, 2020